East Texas Dental Group, Llc | |
212 Old Grande Blvd B224 Tyler TX 75703-4226 | |
(903) 509-0505 | |
(903) 509-0506 |
Full Name | East Texas Dental Group, Llc |
---|---|
Speciality | Dentist |
Location | 212 Old Grande Blvd, Tyler, Texas |
Authorized Official Name and Position | Young T Shim (OWNER) |
Authorized Official Contact | 9035090505 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
East Texas Dental Group, Llc 212 Old Grande Blvd Suite B224 Tyler TX 75703-4226 Ph: (903) 509-0505 | East Texas Dental Group, Llc 212 Old Grande Blvd B224 Tyler TX 75703-4226 Ph: (903) 509-0505 |
NPI Number | 1750743167 |
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Provider Enumeration Date | 03/24/2016 |
Last Update Date | 03/24/2016 |
Identifier | Type | State | Issuer |
---|---|---|---|
1750743167 | NPI | - | NPPES |
352003301 | Medicaid | TX |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
122300000X | Dentist | 31033 (Texas) | Primary |
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